Cross-Pelvic Retrograde Embolization Of An Enlarging Thrombosed Internal Iliac Artery Aneurysm
Alyssa Pyun, MD, Miguel F. Manzur, MD, Fred A. Weaver, MD, Sukgu M. Han, MD, Gregory A. Magee, MD.
University of Southern California, Los Angeles, CA, USA.
Brief Abstract: We present a case of a 76-year-old male with an enlarging thrombosed internal iliac artery aneurysm. Angiographic imaging demonstrated proximal aneurysm thrombosis with no neck or antegrade filling of the aneurysm sac. Through cross-pelvic retrograde access of the aneurysm sac via connecting tortuous collaterals, we were able to use a quadraxial telescoping endovascular system for embolization of the aneurysm nidus thereby obliterating aneurysm sac filling with no major morbidity to the patient. DEMOGRAPHICS: 76-year-old male with asymptomatic bilateral internal iliac artery aneurysms. HISTORY: CT imaging demonstrated a stable patent left internal iliac artery aneurysm of 16mm, however the right internal iliac artery aneurysm, which had spontaneously thrombosed, demonstrated growth to 41mm from 36mm over the course of 13months despite proximal thrombosis, with potential retrograde filling of the aneurysm sac via secondary or tertiary branches. PLAN: Initial angiogram confirmed thrombosis of the right internal iliac artery aneurysm without a visible neck or antegrade flow into the aneurysm sac. The left internal iliac artery was engaged and selective angiogram demonstrated marked tortuosity of cross pelvic collateral circulation feeding from the left internal iliac to the right internal iliac artery aneurysm. The tortuous course of the largest feeding collateral artery was carefully maneuvered across the pelvis, and the nidus of the aneurysm sac growth as well as aneurysm sac itself were coil embolized. The left internal iliac artery aneurysm was addressed with two balloon expandable covered stent grafts and completion angiography demonstrated no aneurysm sac filling of either side. The patient had an uncomplicated hospital course and at 1 month follow up continues to be asymptomatic with no evidence of pelvic ischemia. Follow up CT scan demonstrates a stable thrombosed right internal iliac artery aneurysm with coil embolization of the feeding vasculature. DISCUSSION: Internal iliac artery aneurysms can have continued expansion secondary to retrograde filling despite spontaneous chronic proximal thrombosis, analogous to a type1b endoleak, which can preclude endovascular treatment from an antegrade approach. Alternative techniques described include open repair, direct percutaneous injection, and transgluteal access for embolization, which are often not ideal for the typical vascular patient. Thus, through this technique, endovascular treatment by embolization across the pelvis due to the highly collateralized pelvic circulation can be done, even in highly tortuous vessels.
Back to 2021 ePosters